Name: Mrs.

J
Age: 31 yo
Address: Jonggat
Admitted: June 2nd, 2012 at 10.25

TIME
02/06/
2012
10.25

SUBJECTIVE
Patient pregnant 9 months
came to Policlinic NTB GH
confessed water leaked out
from her womb since 03.30
(17/05/2012). Abdominal
pain (-), Bloody slim (-), FM
(+).
No history of nausea,
vomiting, headache, visual
disturbance and epigastric
pain.
No history of DM, HT,
asthma.
LMP: 16/09/2011
EDD: 23/06/2012
History of ANC: >4x at
Posyandu & PHC
Last ANC: 02/06/2012
History of USG: History of family planning: Pil
Next family planning:
Injection 3 months
Obstetrical history:
I., 7 mo, spontan, midwife,
2000 g, 6 yo, L
II.This

OBJECTIVE
General status:
GC: well
BP: 180/130 mmHg
PR: 92 bpm
RR: 24
T: 36,5
Eye : palor (-), icteric (-)
Thorax :
Cor : S1S2 single reguler
(murmur -), (gallop -)
Pulmo : vesikuler (+/+),
wheezing (-/-),
Ronkhi (-/-).
Abdomen : scar (-), striae (+),
linea nigra (+)
Extremity : edema (-/-), warm
acral (+/+)
Obstetrical status:
L1: breech
L2: back on the left side
L3: head
L4: 4/5
UFH: 31 cm
EFW: 3100 g
UC: FHB: 12-12-12 (144 x/min)
VT: 1 cm, eff 25%, amnion
(+), head palpable HI,
impalpable small part /
umbilical cord.
PS : 5

ASSESTMENT
G2P1A0L1 37
weeks S/L/IU
with PROM +
severe
preeclampsia

PLANNING
Obs mother & fetal
well being
Infus MgS04 40% 4
g bolus, then drip
MgSo4 40% 6 g
Infus RL 28 tpm
Insert DC
Skin test Ampi (-),
inj Ampi 1 g IV
CTG: reactive
DM co SPV, advice:
- Conservative
therapy
- Termination: drip
oxytocin

TIME

SUBJECTIVE

OBJECTIVE

ASSESTMENT

PLANNING

Lab:
HB: 10,9 g/dl
RBC: 4,08 M/dl
WBC: 14,80 K/dl
PLT: 236
HbSAg: (+)
Protein urine : +3
GDS: 88 mg/dl
SC: 0,5
Ureum : 12
Uric acid: 3,8
SGOT : 19
SGPT : 11
15.30

Abdominal pain came and relieved

UC: FHB: 12-11-11 (136)

Flash I
Dryp oxy began 8
tpm

16.00

Abdominal pain came and relieved

UC: FHB: 11-11-11 (132)

Dryp oxy 12 tpm

16.30

Abdominal pain came and relieved

UC: FHB: 11-12-12 (140)

Dryp oxy 16 tpm

17.00

Abdominal pain came and relieved

UC: FHB: 11-11-11 (132)

Dryp oxy 20 tpm

17.30

Abdominal pain came and relieved

UC: 1x/10 ~ 20
FHB: 11-11-12 (136)

Dryp oxy 24 tpm

18.00

Abdominal pain came and relieved

UC: 2x/10 ~ 30
FHB: 11-11-12 (136)

Dryp oxy 28 tpm

18.30

Abdominal pain came and relieved

UC: 2x/10 ~ 30
FHB: 11-11-11 (132)

Dryp oxy 32 tpm

19.00

Abdominal pain came and relieved

UC: 3x/10 ~ 30
FHB: 11-11-11 (132)

Dryp oxy 36 tpm

19.30

Abdominal pain came and relieved

UC: 3x/10 ~ 30

Dryp oxy 40 tpm

TIME

SUBJECTIVE

OBJECTIVE

ASSESTMENT

PLANNING

20.00

Abdominal pain came and

relieved

UC: 3x/10 ~ 35
FHB: 11-11-12 (136)

Dryp oxy 40 tpm

20.30

Abdominal pain came and

relieved

UC: 3x/10 ~ 35
FHB: 11-11-11 (132)

Dryp oxy 40 tpm

21.00

Abdominal pain came and

relieved

UC: 3x/10 ~ 35
FHB: 11-11-11 (132)

Dryp oxy 40 tpm

21.30

Abdominal pain came and

relieved + water came out
from her womb

UC: 3x/10 ~ 40
FHB: 11-11-11 (132)
VT: 6 cm, eff 75%, amnion
(-), clear, head palpable HII,
impalpable small part /
umbilical cord.

22.00

Abdominal pain came and

relieved

UC: 3x/10 ~ 40
FHB: 11-11-12 (136)

Flash II
Dryp oxy 40 tpm

22.30

Abdominal pain came and

relieved

UC: 4x/10 ~ 40
FHB: 11-12-12 (140)

Dryp oxy 40 tpm

23.00

Abdominal pain ++
Mother wants to bearing
down

UC: 4x/10 ~ 45
FHB: 12-12-12 (144)
doranteknusperjolvulka

23.15

G2P1A0L1 37
weeks S/L/IU
active phase 1st
stage of labor
with history
rupture of
membrane +
severe
preeclampsia

G2P1A0L1 37
weeks S/L/IU 2nd
stage of labor
with history
rupture of
membrane +
severe
preeclampsia

Dryp oxy 40 tpm

Dryp oxy 40 tpm

Conduct mother to
bearing down

Baby was born, male,

AS 7-9, 2800 gram,
49 cm, Anus (+),
congenital anomaly
(-)

TIME

SUBJECTIVE

OBJECTIVE

ASSESTMENT

PLANNING

03/06/
2012
01.15

Patient confessed blood

came out from her womb

GC: well
Cons: CM
BP: 170/110
HR: 84 bpm
RR: 22 tpm
T: 36,5 C
UC: +
UFH: 2 fingers below
umbilicus
AB: -

2 hours post
partum

Observed mother
and baby well being
Observed bleeding &
VS mother
Suggest mother to
mobilisation, eat &
drink.

07.00

Delivery wound pain

GC: well
BP: 140/90

One day post

partum

Observed mother
and baby well being
Suggest mother to
mobilisation, eat,
and drink,
medication.

Two days post

partum

Observed mother
and baby well being
Suggest mother to
mobilisation, eat,
and drink,
medication.

Cons: CM
HR : 80 bpm

RR : 20 tpm
T : 36,4 C
UFH : 2 fingers below
umbilicus
UC : +
AB : Baby rooming in:
PR:144
RR: 46
T: 36,4
04/06/
2012
07.00

GC: well
BP: 110/80

Cons: CM
HR : 80 bpm

RR : 20 tpm
T : 36,4 C
UFH : 2 fingers below
umbilicus
UC : +
AB : Baby rooming in:
PR:144
RR: 46
T: 36,4